This case was transferred to The Phia Group’s Third Party Liability Attorneys by another subrogation vendor, at the request of the Arizona Self-funded health plan. The subrogation vendor failed to recoup any funds even though they had over two years to do so. The Plan participant’s dependent was involved in a severe motorcycle accident and there were reportedly policy limits of $100,000. After an in depth review of the file and the Summary Plan Description, The Phia Group discovered that the patient may not have been eligible for some of the later paid plan benefits after a subsequent termination date and the previous third party liability vendor failed to request refunds of the overpayments from providers, and focused instead entirely on the motorcycle’s policy. The Phia Group’s TPL Attorneys used these potential overpayments to their advantage. After failing to convince The Phia Group to waive reimbursement rights, the parties involved requested a 50% reduction of the Plan’s lien. The Phia Group refused and entered into negotiations knowing that it could recoup funds from the providers (overpayments) as well. As a result, this case was finalized within three months and the Plan received close to full recovery.

Plan Exposure:

$200,000

Phia Intervention Saved:

$150,000

Case Study #2

The Phia Group was forwarded a case by a Medicare Advantage Plan administrator, after they were unable to resolve their lien with the patient’s attorney. The patient, who was enrolled in this Medicare Advantage Plan, was involved in a motor vehicle accident in the State of Nevada. She retained an attorney to pursue the driver that caused the injury and to file a liability claim against the auto insurance carrier. The plan administrator attempted to place the attorney on notice of their right to reimbursement, but received no feedback and could not obtain a response from the attorney. Based on the lack of cooperation of the parties involved, the case was forwarded to The Phia Group’s Medicare Recovery Specialists. The Phia Group cited Nevada law, reminding the attorney of his professional obligations as well as the rights of the plan under applicable State, Federal, and Medicare laws. The Phia Group not only received a response from the attorney, but secured an agreement signed by the attorney to hold all settlement proceeds in trust and to honor the Medicare plan’s rights in full.

Plan Exposure:

$160,000

Phia Intervention Saved:

$145,000

Case Study #3

In this particular case we represented a Self-Funded Benefit Plan, which had paid $140,000 in medical bills on behalf of the injured party. Of the $140,000, a reinsurance carrier had reimbursed the Plan $75,000.

The Phia Group received a call from the Plan advising that the reinsurance carrier had retained its own counsel to pursue the $75,000 it had paid. The Plan further explained that the reinsurance carrier’s attorney advised closing the file because the patient’s attorney had raised a made whole argument (third party funds were inadequate and failed to fully compensate the patient).

The patient was going to receive a $50,000 policy limit, which was significantly less than their losses. The Phia Group contacted the attorney to gather additional details and determined that the patient was not only receiving a $50,000 policy limit; they were also pursuing a $250,000 underinsured motorist claim. Upon receipt of this information we reviewed the Plan Document and applicable law regarding the Plan’s right to reimbursement. The Plan language expressed a clear right of reimbursement from underinsured motorist claims.

The Phia Group’s Third Party Liability Lawyers contacted the reinsurance carrier’s Third Party Recovery vendor and obtained permission to take the lead on this file. With permission to fully handle the file The Phia Group was able to negotiate with the attorney and secure a recovery for both the Plan and the reinsurance carrier.

Plan Exposure:

$140,000

Phia Intervention Saved:

$Exceeding 75,000

Case Study #4

This case involved a motor vehicle accident where a state government official’s daughter was a passenger in a car, whose driver was found to be at fault for a serious accident. Both the passenger and driver died due to the severity of their injuries (over $600,000 in related claims paid).

The passenger received health benefits through a self-funded benefit plan whose TPA had an in-house subrogation department. They conducted research and spoke with several attorneys until they came to the conclusion that due to applicable State law, no recovery could be made.

In 2008, the stop-loss carrier, having paid over $500,000 in claims relating to this incident, forwarded the matter to The Phia Group’s attention. The stop-loss carrier also suggested that the TPA have The Phia Group represent its interests as well. Within six months The Phia Group’s Third Party Reimbursement Team was able to secure a recovery on behalf of the stop-loss carrier and the benefit plan.

Plan Exposure: $700,000

Phia Intervention Saved: $400,000

Case Study #5

In a New Jersey matter, a man was hit by a truck while walking to work. There was close to $800,000 in medical expenses paid. The stop-loss carrier reimbursed the benefit plan involved.

When faced with hostile law, the benefit plan’s in-house subrogation department failed to pursue the potential recovery opportunity. The stop-loss carrier then exercised its right to take over reimbursement operations. The stop-loss carrier forwarded this case to The Phia Group’s ERISA Attorneys for handling. The Phia Group recovered almost 100% of the lien.

Plan Exposure: $800,000

Phia Intervention Saved: $590,000

Case Study #6

While passing a law in New York that was hostile to self-funded plans seeking recoveries, the legislature stated its intent that it pre-empt ERISA. In a third-party recovery matter, a TPA was pursuing its own third party subrogation collection on behalf of a plan governed by ERISA. The TPA had received arguments from the member’s attorney citing the NY law as evidence that no recovery was permitted. The TPA was ready to concede the argument, but decided to run it by The Phia Group’s ERISA Lawyers for one last look before forfeiting the Plan’s recovery.

The ERISA Lawyer engaged the participant’s counsel in legal argument and ultimately forced the attorney to realize that the New York insurance law did not hinder this particular plan’s recovery. The Phia Group recovered 66% of the lien (because the lien amount exceeded the available settlement funds).

Plan Exposure: $380,000

Phia Intervention Saved: $250,000

Case Study #7

A plan participant of a non-ERISA pan was involved in a motor vehicle accident in Virginia, and incurred almost $130,000 in medical expenses. As Virginia has an anti-subrogation statute which prohibits subrogation and reimbursement, the plaintiff’s attorney took the position that the Plan had no rights to reimbursement. However, a Third Party Liability Lawyer with The Phia Group, LLC crafted a choice of law argument that as opposed to subrogation, reimbursement rights are a matter of contract between the Plan and plan participant, and would therefore be governed, under Virginia’s choice of law rules, by the law of the jurisdiction where the contract was formed. This would be North Carolina. Although North Carolina also has an anti-subrogation statute, there is an exception for this particular type of plan, a church plan.